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A nurse is contributing to the plan of care for a client who has urolithiasis. Which of the following interventions should the nurse include in the plan?
- A. Tell the client to expect a decrease in urine output.
- B. Provide the client a high protein diet.
- C. Maintain the client on bed rest.
- D. Encourage the client to drink 3 L of fluids per day.
Correct Answer: D
Rationale: Encouraging the client to drink 3 L of fluids per day helps flush out stones, prevent new stone formation, and reduce urinary concentration.
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A nurse is caring for a client who has benign prostatic hyperplasia (BPH). Which of the following findings should the nurse expect?
- A. Difficulty starting the flow of urine.
- B. Painful urination.
- C. Urge incontinence.
- D. Critically elevated prostate-specific antigen (PSA) level.
Correct Answer: A
Rationale: Difficulty starting urine flow is common in BPH due to prostate enlargement obstructing the urethra.
A nurse is assisting with the care of a client who has hypertension and chronic kidney disease. The client is scheduled for hemodialysis. Which of the following actions should the nurse plan to take while caring for this client? (Select all that apply.)
- A. Obtain the client's weight.
- B. Verify the glomerular filtration rate.
- C. Check the graft site for a palpable thrill.
- D. Document vital signs.
- E. Administer a sedative to the client.
Correct Answer: A,C,D
Rationale: Obtaining the client's weight, checking the graft site for a palpable thrill, and documenting vital signs are essential to monitor fluid balance, ensure vascular access functionality, and detect complications during hemodialysis.
A nurse is collecting data from a client who has systemic lupus erythematosus. Which of the following findings is the highest priority to report to the provider?
- A. Client reports feeling depressed.
- B. Joint pain in hands and knees.
- C. Dry, raised rash on the face.
- D. Presence of peripheral edema.
Correct Answer: D
Rationale: Peripheral edema is the highest priority as it may indicate kidney involvement, a serious SLE complication requiring immediate attention.
A nurse is collecting data from a client who has right-sided heart failure. Which of the following findings should the nurse expect?
- A. Frothy sputum.
- B. Orthopnea.
- C. Dyspnea.
- D. Peripheral edema.
Correct Answer: D
Rationale: Peripheral edema is a common finding in right-sided heart failure due to blood backup in systemic circulation, causing fluid accumulation in tissues.
A nurse is reinforcing teaching with a client who has osteoarthritis and is taking acetaminophen for pain management. Which of the following statements should the nurse include in the teaching?
- A. Apply an ice pack to painful joints for 20 minutes, 3 times a day.
- B. Take a dose of aspirin on days when you have more pain.
- C. Increase your water intake to 2 liters per day.
- D. Participate in high impact aerobics to increase joint mobility.
Correct Answer: C
Rationale: Increasing water intake to 2 liters daily supports joint lubrication and overall health in osteoarthritis management.